NRS 695F.430 Provision
of services excluded from practice of any healing arts; solicitation excluded
from statutory provisions regarding solicitation or advertising by practitioner
of healing art.

ELIGIBILITY FOR COVERAGE

NRS 695F.440 Effect
of eligibility for medical assistance under Medicaid; assignment of rights to
state agency.

NRS 695F.450 Organization
prohibited from asserting certain grounds to deny enrollment of child pursuant
to order if parent is insured.

NRS 695F.460 Certain
accommodations to be made when child is covered under evidence of coverage of
noncustodial parent.

NRS 695F.470 Organization
to authorize enrollment of child of parent who is required by order to provide
medical coverage under certain circumstances; termination of coverage of child.

NRS 695F.480 Organization
prohibited from restricting coverage of child based on preexisting condition if
person who is eligible for group coverage adopts or assumes legal obligation
for child.

_________

_________

GENERAL PROVISIONS

NRS 695F.010Definitions.As
used in this chapter, unless the context otherwise requires, the words and
terms defined in NRS 695F.020 to 695F.070, inclusive, have the meanings ascribed to
them in those sections.

NRS 695F.020“Enrollee” defined.“Enrollee”
means a person, including the dependents of the person, who is entitled to a
limited health service pursuant to a contract with a person authorized to
provide or arrange for that service pursuant to this chapter.

NRS 695F.043“Medicaid” defined.“Medicaid”
means a program established in any state pursuant to Title XIX of the Social
Security Act (42 U.S.C. §§ 1396 et seq.) to provide assistance for part or all
of the cost of medical care rendered on behalf of indigent persons.

NRS 695F.047“Order for medical coverage” defined.“Order
for medical coverage” means an order of a court or administrative tribunal to
provide medical coverage to a child pursuant to the provisions of 42 U.S.C. §
1396g-1.

(c) A provider who provides or arranges for the
provision of a limited health service pursuant to a contract with a prepaid
limited health service organization or person described in paragraph (a) or
(b).

NRS 695F.070“Subscriber” defined.“Subscriber”
means a person whose employment or other status, except for family dependency,
is the basis for his or her entitlement to receive a limited health service
pursuant to a contract with a person authorized to provide or arrange for that
service pursuant to this chapter.

NRS 695F.080General applicability of title 57 of NRS.Except as otherwise provided in this chapter
or in specific provisions of this title, the provisions of this title are not
applicable to any prepaid limited health service organization granted a certificate
of authority pursuant to this chapter. This section does not apply to an
insurer licensed and regulated pursuant to this title except with respect to
its activities as a prepaid limited health service organization authorized and
regulated pursuant to this chapter.

NRS 695F.090Applicable statutory provisions. [Effective through December 31,
2013.]Prepaid limited health
service organizations are subject to the provisions of this chapter and to the
following provisions, to the extent reasonably applicable:

10. NRS
680B.025 to 680B.039, inclusive,
concerning premium tax, premium tax rate, annual report and estimated quarterly
tax payments. For the purposes of this subsection, unless the context otherwise
requires that a section apply only to insurers, any reference in those sections
to “insurer” must be replaced by a reference to “prepaid limited health service
organization.”

NRS 695F.090Applicable statutory
provisions. [Effective January 1, 2014.]Prepaid
limited health service organizations are subject to the provisions of this
chapter and to the following provisions, to the extent reasonably applicable:

10. NRS
680B.025 to 680B.039, inclusive,
concerning premium tax, premium tax rate, annual report and estimated quarterly
tax payments. For the purposes of this subsection, unless the context otherwise
requires that a section apply only to insurers, any reference in those sections
to “insurer” must be replaced by a reference to “prepaid limited health service
organization.”

NRS 695F.100Certificate required.A
person shall not operate a prepaid limited health service organization in this
state unless the person has been issued a certificate of authority by the
Commissioner pursuant to this chapter.

NRS 695F.110Application for certificate.An
application for a certificate of authority to operate a prepaid limited health
service organization must be filed with the Commissioner on a form prescribed
by the Commissioner. The application must be verified by an officer or
authorized representative of the applicant and include:

1. A copy of the applicant’s basic organizational
document, including any articles of incorporation, articles of association,
partnership agreement, trust agreement or any other applicable document or
amendment thereto.

2. A copy of the bylaws, rules and
regulations or similar documents, if any, which regulate the conduct of the
internal affairs of the applicant.

3. A list of the names, addresses,
official positions and biographical information of the persons responsible for
conducting the applicant’s affairs, including, but not limited to:

(a) The members of the board of directors;

(b) The members of the board of trustees;

(c) The members of the executive committee or
other governing board or committee;

(d) The principal officers;

(e) Any person owning or having the right to
acquire 10 percent or more of the voting securities of the applicant; and

(f) If the applicant is a partnership or
association, the partners or members of that partnership or association.

4. A statement generally describing the
applicant, its facilities, employees and the limited health service or services
to be offered.

5. A copy of any contract made or to be
made between the applicant and any provider concerning the provision of a
limited health service to enrollees.

6. A copy of any contract made, or to be
made between the applicant and any person described in subsection 3.

7. A copy of any contract made or to be
made between the applicant and any person for the performance on the
applicant’s behalf of any functions, including, but not limited to, marketing, administration,
enrollment, management of investments and subcontracting for the provision of a
limited health service to enrollees.

8. A copy of the form of any group
contract which is to be issued to employers, unions, trustees or other
organizations.

9. A copy of any form for evidence of
coverage to be issued to subscribers.

10. A copy of the applicant’s most recent
financial statements which have been audited by an independent certified public
accountant. If the financial affairs of the parent company of the applicant are
audited by an independent certified public accountant and the financial affairs
of the applicant are not audited, the applicant must submit a copy of the most
recently audited financial statement of the parent company which was certified
by an independent certified public accountant and the consolidating financial
statements of the applicant, unless the Commissioner determines that additional
or more recent financial information is required.

11. A copy of the applicant’s financial
plan, including a 3-year projection of the anticipated operating results, a
statement of the sources of working capital and any other sources of funding
and any plan for contingencies.

12. A schedule of the rates and charges
for the limited health service.

13. A description of the proposed method
of marketing.

14. A statement acknowledging that any
process in any legal action or proceeding against the applicant on a cause of
action arising in this state is valid if lawfully served.

15. A description of the procedure for the
resolution of complaints submitted by enrollees concerning the limited health
service provided by the prepaid limited health service organization.

16. A description of the procedures to be
established for quality assessment and utilization review.

17. A description of the applicant’s plan
to comply with the provisions of NRS 695F.200.

18. All applicable fees for filing an
application for a certificate of authority.

19. Such other information as the
Commissioner may require to make the determination required by this chapter.

1. The Commissioner shall review each
application and notify the applicant of any deficiency contained in the
application.

2. The Commissioner shall issue a
certificate of authority to an applicant if:

(a) The applicant has complied with the
requirements set forth in NRS 695F.110;

(b) The persons responsible for conducting the
applicant’s affairs are competent, trustworthy and possess good reputations,
and have the appropriate experience, training or education;

(c) The applicant is financially responsible and
may reasonably be expected to carry out its obligations to enrollees and
prospective enrollees; and

(d) The agreements with providers for the limited
health service include the provisions required by NRS
695F.220.

3. The Commissioner may, when determining
whether an applicant complies with the requirements of paragraph (c) of
subsection 2, consider:

(a) The financial soundness of the applicant’s
arrangements for the provision of a limited health service and the schedule of
rates, deductibles, copayments and other charges used in connection therewith;

(b) The adequacy of working capital, any other
sources of funding and any provisions for contingencies;

(c) Any agreement for paying the cost of a
limited health service or for alternative coverage if the prepaid limited
health service organization becomes insolvent; and

(d) The applicant’s manner of compliance with the
requirements of NRS 695F.200.

NRS 695F.130Application of person who is licensed as insurer or holds
another certificate of authority.Any
person who is licensed as an insurer pursuant to chapter
680A of NRS or issued a certificate of authority pursuant to chapter 695A, 695B
or 695C of NRS may submit an application to
the Commissioner for a certificate of authority to provide a limited health
service in this state. The application must include the information requested
by subsections 4, 5, 7, 8, 10, 11, 12 and 15 of NRS
695F.110 and any subsequent material changes or additions thereto.

1. If the Commissioner denies an
application for a certificate of authority of a person who files an application
pursuant to NRS 695F.120 or 695F.130, the Commissioner shall send a written
notice to the applicant. The notice must include the reason for the denial of
the certificate.

2. The applicant may, within 30 days after
it receives the notice, submit to the Commissioner a written request for a
hearing on the matter. The Commissioner shall hold a hearing within 30 days
after the Commissioner receives the request.

3. The hearing must be held in the manner
set forth in NRS 679B.310 to 679B.370, inclusive. The decision of the
Commissioner is a final decision for the purpose of judicial review.

NRS 695F.153Coverage for prescription drugs: Provision of notice and
information regarding use of formulary.

1. A prepaid limited health service
organization that offers or issues evidence of coverage which provides coverage
for prescription drugs shall include with any evidence of that coverage
provided to a subscriber, notice of whether a formulary is used and, if so, of
the opportunity to secure information regarding the formulary from the
organization pursuant to subsection 2. The notice required by this subsection
must:

(a) Be in a language that is easily understood
and in a format that is easy to understand;

(b) Include an explanation of what a formulary
is; and

(c) If a formulary is used, include:

(1) An explanation of:

(I) How often the contents of the
formulary are reviewed; and

(II) The procedure and criteria for
determining which prescription drugs are included in and excluded from the
formulary; and

(2) The telephone number of the
organization for making a request for information regarding the formulary pursuant
to subsection 2.

2. If a prepaid limited health service
organization offers or issues evidence of coverage which provides coverage for
prescription drugs and a formulary is used, the organization shall:

(a) Provide to any enrollee or participating
provider of health care, upon request:

(1) Information regarding whether a
specific drug is included in the formulary.

(2) Access to the most current list of
prescription drugs in the formulary, organized by major therapeutic category,
with an indication of whether any listed drugs are preferred over other listed
drugs. If more than one formulary is maintained, the organization shall notify
the requester that a choice of formulary lists is available.

(b) Notify each person who requests information
regarding the formulary, that the inclusion of a drug in the formulary does not
guarantee that a provider of health care will prescribe that drug for a
particular medical condition.

1. Except as otherwise provided in this
section, evidence of coverage which provides coverage for prescription drugs
must not limit or exclude coverage for a drug if the drug:

(a) Had previously been approved for coverage by
the prepaid limited health service organization for a medical condition of an
enrollee and the enrollee’s provider of health care determines, after
conducting a reasonable investigation, that none of the drugs which are
otherwise currently approved for coverage are medically appropriate for the
enrollee; and

(b) Is appropriately prescribed and considered
safe and effective for treating the medical condition of the enrollee.

2. The provisions of subsection 1 do not:

(a) Apply to coverage for any drug that is
prescribed for a use that is different from the use for which that drug has
been approved for marketing by the Food and Drug Administration;

(b) Prohibit:

(1) The organization from charging a
deductible, copayment or coinsurance for the provision of benefits for
prescription drugs to the enrollee or from establishing, by contract,
limitations on the maximum coverage for prescription drugs;

(2) A provider of health care from prescribing
another drug covered by the evidence of coverage that is medically appropriate
for the enrollee; or

(c) Require any coverage for a drug after the
term of the evidence of coverage.

3. Any provision of an evidence of
coverage subject to the provisions of this chapter that is delivered, issued
for delivery or renewed on or after October 1, 2001, which is in conflict with
this section is void.

NRS 695F.160Rates and charges: Reasonableness.The
rates and charges for a limited health service must be reasonable. The
commissioner may request information from the prepaid limited health service
organization to determine the reasonableness of those rates and charges.

1. A prepaid limited health service
organization shall file with the Commissioner a notice of any change in the
rates, charges, benefits or any material change of any matter or document
furnished pursuant to NRS 695F.110. The
organization shall submit any proof necessary to justify the change. No such
change is effective unless it is approved by the Commissioner. If the
Commissioner does not disapprove of the change within 60 days after the notice
is filed, the change shall be deemed approved.

2. If a prepaid limited health service
organization wishes to add a limited health service, it shall submit:

(a) An application to the Commissioner;

(b) The information required by NRS 695F.110, if the information is different from
the information filed with the prepaid limited health service organization’s
application; and

Ê A prepaid
limited health service organization may not add a limited health service if the
Commissioner determines that adding the service would qualify the organization
as a health maintenance organization pursuant to chapter
695C of NRS or as an offeror of a health care plan for which a certificate
of authority is required by any other provisions of this title.

3. If the Commissioner does not deny the
application within 60 days after it is filed, the application shall be deemed
approved.

4. If the application is denied, the
Commissioner shall send a written notice to the prepaid limited health service
organization. The notice must include the reason for the denial. The prepaid
limited health service organization may request a hearing in the manner set
forth in NRS 695F.140.

NRS 695F.180Investments.The
money of the prepaid limited health service organization must be invested in
accordance with the guidelines established by the National Association of
Insurance Commissioners for investments by health maintenance organizations.

1. A prepaid limited health service
organization shall set aside a reserve equal to 3 percent of the premiums
collected from its enrollees in an amount not to exceed $500,000. The reserve is
in addition to the bond or deposit filed with the Commissioner.

2. The reserve:

(a) Must be deposited in a trust account in a
financial institution which is located in this state and which is federally
insured or insured by a private insurer approved pursuant to NRS 678.755. The income earned on money in
the account must be paid to the organization and used for its operations.

(b) Is in addition to the reserve established by
the organization according to good business and accounting practices for
incurred but unreported claims and other similar claims.

1. Capital account with a net worth of not
less than $200,000 unless a lesser amount is permitted in writing by the
Commissioner. The account must not be obligated for any accrued liabilities and
must consist of cash, securities or a combination thereof which is acceptable
to the Commissioner.

2. Surety bond or deposit of cash or
securities for the protection of enrollees of not less than $250,000.

1. A prepaid limited health service
organization shall maintain in force a fidelity bond in its own name on its
officers and employees in an amount not less than $1,000,000 or in any other
amount prescribed by the Commissioner.

2. Except as otherwise provided in
subsection 3, the bond must be issued by an insurer licensed to do business in
this State.

3. If the fidelity bond is not available
from an insurer licensed to do business in this State, a prepaid limited health
service organization may procure a fidelity bond from a surplus lines broker
licensed pursuant to chapter 685A of NRS.

4. In lieu of the bond required pursuant
to subsection 1, a prepaid limited health service organization may deposit with
the Commissioner cash, securities or other investments described in NRS 695F.180. The deposit must be maintained in joint
custody with the Commissioner in the amount and subject to the same conditions
required for a bond pursuant to this subsection.

NRS 695F.215Required contract with insurance company for provision of
insurance, indemnity or reimbursement against cost of health care services.A prepaid limited health service organization
shall contract with an insurance company licensed in this State or authorized
to do business in this State for the provision of insurance, indemnity or
reimbursement against the cost of health care services provided by the prepaid
limited health service organization.

NRS 695F.220Contract between organization and provider or subcontractor for
provision of services to enrollees.Each
contract between a prepaid limited health service organization and a provider
or other person subcontracting for the provision of a limited health service to
enrollees on a prepayment basis or any other basis must contain the following
terms and conditions:

1. If the prepaid limited health service
organization fails to pay for a limited health service for any reason,
including, but not limited to, insolvency or breach of this contract, the
enrollees are not liable to the provider for any money owed to the provider
pursuant to this contract.

2. A provider, agent, trustee or assignee
thereof may not maintain an action at law or attempt to collect from an
enrollee any money which the prepaid limited health service organization owes
to the provider.

3. These provisions do not prohibit the
collection of any uncovered charges which an enrollee agreed to pay or the
collection of any copayment from an enrollee.

4. These provisions survive the
termination of this contract, regardless of the reason for the termination.

5. The termination of this contract does
not release the provider from its obligation to complete any procedure on an
enrollee who is receiving treatment for a specific condition for a period not
to exceed 60 days, at the same schedule of copayment or any other applicable
charge in effect when this contract is terminated.

6. Any amendment to the provisions of this
contract must be submitted to the Commissioner for approval before the
amendment is effective.

1. Each prepaid limited health service
organization shall establish a system for the resolution of written complaints
submitted by enrollees and providers.

2. The provisions of subsection 1 do not
prohibit an enrollee or provider from filing a complaint with the Commissioner
or limit the Commissioner’s authority to investigate such a complaint.

3. Each prepaid limited health service
organization that issues any evidence of coverage that provides, delivers,
arranges for, pays for or reimburses any cost of health care services through
managed care shall provide a system for resolving any complaints of an enrollee
or subscriber concerning those health care services that complies with the
provisions of NRS 695G.200 to 695G.310, inclusive.

1. The Commissioner may examine the
affairs of any prepaid limited health service organization as often as is
reasonably necessary to protect the interests of the residents of this State, but
not less frequently than once every 3 years.

2. A prepaid limited health service
organization shall make its books and records available for examination and
cooperate with the Commissioner to facilitate the examination.

3. In lieu of such an examination, the
Commissioner may accept the report of an examination conducted by the
commissioner of insurance of another state.

4. The reasonable expenses of an
examination conducted pursuant to this section must be charged to the
organization being examined and remitted to the Commissioner.

NRS 695F.320Reports to Commissioner; fine and suspension for noncompliance.

1. Each prepaid limited health service
organization shall file with the Commissioner annually, on or before March 1, a
report showing its financial condition on the last day of the preceding
calendar year. The report must be verified by at least two principal officers
of the organization.

2. The report must be on a form prescribed
by the Commissioner and include:

(a) A financial statement of the organization,
including its balance sheet and receipts and disbursements for the preceding
calendar year;

(b) The number of subscribers at the beginning
and the end of the year and the number of enrollments terminated during the
year; and

(c) Such other information as the Commissioner
may prescribe.

3. Each prepaid limited health service
organization shall file with the Commissioner annually an audited financial
statement prepared by an independent certified public accountant. The statement
must cover the most recent fiscal year of the organization and must be filed
with the Commissioner within 120 days after the end of that fiscal year.

4. The Commissioner may require more
frequent reports containing such information as is necessary to enable the
Commissioner to carry out his or her duties pursuant to this chapter.

5. The Commissioner may:

(a) Assess a fine of not more than $100 per day
for each day the report or financial statement required pursuant to this
section is not filed after the report or financial statement is due, but the
fine must not exceed $3,000; and

(b) Suspend the organization’s certificate of
authority until the organization files the report.

NRS 695F.330Payment of tax.At
the time of filing the annual report pursuant to NRS
695F.320 the prepaid limited health service organization shall forward to
the Department of Taxation the tax and any penalty for nonpayment or delinquent
payment of the tax in accordance with the provisions of chapter 680B of NRS.

1. The Commissioner may suspend or revoke
the certificate of authority of a prepaid limited health service organization
issued pursuant to this chapter if the Commissioner determines that:

(a) The prepaid limited health service
organization is operating substantially in violation of its basic
organizational document or in a manner contrary to the manner described in and
reasonably inferred from any other information submitted pursuant to NRS 695F.110 unless any amendment to its basic
organization document or other information has been filed with and approved by
the Commissioner;

(b) The prepaid limited health service
organization issued an evidence of coverage or used rates or charges which do
not comply with the requirements of NRS 695F.150
and 695F.160;

(c) The prepaid limited health service
organization is not able to carry out its obligations to provide its limited
health service;

(d) The prepaid limited health service
organization is not financially responsible and may reasonably be expected to
be unable to carry out its obligations to enrollees or prospective enrollees;

(e) The capital of the prepaid limited health
service organization is less than the amount required by NRS 695F.200 or the organization has failed to
correct any deficiency concerning its capital as required by the Commissioner;

(f) The prepaid limited health service
organization has failed to establish and maintain in a reasonable manner the
complaint system required by NRS 695F.230;

(g) The continued operation of the prepaid
limited health service organization would be hazardous to its enrollees; or

(h) The prepaid limited health service
organization has failed to comply with any other provision of this chapter.

2. If the Commissioner has cause to
believe that grounds for the suspension or revocation of a certificate of
authority of a prepaid limited health service organization exist, the
Commissioner shall send written notice to the organization. The notice must
include the reason for the suspension or revocation and a time not more than 30
days thereafter for a hearing on the matter. The hearing must be held in the
manner set forth in NRS 695F.140.

3. If the certificate of authority of a
prepaid limited health service organization is revoked, the organization shall
proceed, immediately following the effective date of the order of revocation, to
wind up its affairs. The organization shall not:

(a) Conduct any further business unless it is
essential for the orderly conclusion of its affairs; and

(b) Engage in any further advertising or
solicitation.

4. The Commissioner may, by written order,
permit such further operation of the organization as the Commissioner considers
necessary to enable the enrollees to obtain limited health services from
another organization or provider.

NRS 695F.360Violations of chapter: Order to cease and desist; fine.If the Commissioner, after a hearing held
pursuant to NRS 695F.140, finds that a prepaid
limited health service organization or other person subject to this chapter has
violated a provision of this chapter, the Commissioner may:

1. Issue and cause to be served upon the
organization or any other person charged with a violation of this chapter, a
copy of the findings of the Commissioner and an order directing the
organization or person to cease and desist from engaging in the act or practice
which constitutes the violation; and

2. Impose a fine of not more than $1,000
for each violation, not to exceed a total amount of $10,000.

NRS 695F.400License required to apply, procure, negotiate or place for
another any policy or contract of organization.A
person shall not apply, procure, negotiate or place for another person any
policy or contract of a prepaid limited health service organization unless he
or she holds a license issued pursuant to chapter
683A of NRS.

1. Any information relating to the
diagnosis, treatment or health of any enrollee obtained from the enrollee or
from any provider by a prepaid limited health service organization and any
contract with a provider submitted pursuant to the requirements of this chapter
must not be disclosed to any person except:

(a) To the extent that it is necessary to carry
out the provisions of this chapter;

(b) Upon the written consent of the enrollee or
applicant, provider or prepaid limited health service organization, as
appropriate;

(c) Pursuant to a specific statute or court order
for the production of evidence or the discovery thereof; or

(d) For a claim or legal action if that data or
information is relevant.

2. A prepaid limited health service
organization may claim any privilege against disclosure which the provider who
furnished the information relating to the diagnosis, treatment or health of an
enrollee or applicant to the organization is entitled to claim.

NRS 695F.420Certain insurers and organizations may exclude coverage
duplicated pursuant to this chapter.Notwithstanding
any other provision of this title, any person who is licensed as an insurer
pursuant to chapter 680A of NRS or issued a
certificate of authority pursuant to chapter
695A, 695B or 695C of NRS may exclude, in any contract or
policy issued to a group, any coverage which would duplicate the coverage of a
limited health service, whether for services, supplies or reimbursement, to the
extent that the coverage or service is provided in accordance with this chapter
pursuant to a contract or policy issued to the same group or to a part of that
group by a prepaid limited health service organization or a person who is
licensed as an insurer pursuant to chapter 680A
of NRS or issued a certificate of authority pursuant to chapter 695A, 695B
or 695C of NRS.

NRS 695F.430Provision of services excluded from practice of any healing
arts; solicitation excluded from statutory provisions regarding solicitation or
advertising by practitioner of healing art.

1. The provision of limited health
services by a prepaid limited health service organization or any other person
pursuant to this chapter shall not be deemed to be the practice of medicine or
any other healing arts.

2. The solicitation by a prepaid limited
health service organization to arrange for or provide a limited health service
in accordance with this chapter does not violate any statutory provision
relating to solicitation or advertising by a practitioner of a healing art.

NRS 695F.440Effect of eligibility for medical assistance under Medicaid;
assignment of rights to state agency.

1. An organization shall not, when
considering eligibility for coverage or making payments under any evidence of
coverage, consider the availability of, or eligibility of a person for, medical
assistance under Medicaid.

2. To the extent that payment has been made
by Medicaid for health care, a prepaid limited health service organization:

(a) Shall treat Medicaid as having a valid and
enforceable assignment of benefits due a subscriber or claimant under the
subscriber regardless of any exclusion of Medicaid or the absence of a written
assignment; and

(b) May, as otherwise allowed by its evidence of
coverage or contract and applicable law or regulation concerning subrogation,
seek to enforce any rights of a recipient of Medicaid against any other liable
party if:

(1) It is so authorized pursuant to a
contract with Medicaid for managed care; or

(2) It has reimbursed Medicaid in full for
the health care provided by Medicaid to its subscriber.

3. If a state agency is assigned any
rights of a person who is:

(a) Eligible for medical assistance under
Medicaid; and

(b) Covered by any evidence of coverage,

Ê the prepaid
limited health service organization that issued the evidence of coverage shall
not impose any requirements upon the state agency except requirements it
imposes upon the agents or assignees of other persons covered by any evidence
of coverage.

4. If a state agency is assigned any
rights of a subscriber who is eligible for medical assistance under Medicaid, a
prepaid limited health service organization shall:

(a) Upon request of the state agency, provide to
the state agency information regarding the subscriber to determine:

(1) Any period during which the
subscriber, the spouse or a dependent of the subscriber may be or may have been
covered by the organization; and

(2) The nature of the coverage that is or
was provided by the organization, including, without limitation, the name and
address of the subscriber and the identifying number of the evidence of
coverage;

(b) Respond to any inquiry by the state agency
regarding a claim for payment for the provision of any medical item or service
not later than 3 years after the date of the provision of the medical item or
service; and

(c) Agree not to deny a claim submitted by the
state agency solely on the basis of the date of submission of the claim, the
type or format of the claim form or failure to present proper documentation at
the point of sale that is the basis for the claim if:

(1) The claim is submitted by the state
agency not later than 3 years after the date of the provision of the medical
item or service; and

(2) Any action by the state agency to
enforce its rights with respect to such claim is commenced not later than 6
years after the submission of the claim.

NRS 695F.450Organization prohibited from asserting certain grounds to deny
enrollment of child pursuant to order if parent is insured.A prepaid limited health service organization
shall not deny the enrollment of a child pursuant to an order for medical
coverage under any evidence of coverage pursuant to which a parent of the child
is insured on the ground that the child:

1. Was born out of wedlock;

2. Has not been claimed as a dependent on
the parent’s federal income tax return; or

3. Does not reside with the parent or
within the organization’s geographic area of service.

NRS 695F.460Certain accommodations to be made when child is covered under
evidence of coverage of noncustodial parent.If
a child has coverage under any evidence of coverage pursuant to which a
noncustodial parent of the child is insured, the prepaid limited health service
organization issuing that evidence of coverage shall:

1. Provide to the custodial parent such
information as necessary for the child to obtain any benefits under that
coverage.

2. Allow the custodial parent or, with the
approval of the custodial parent, a provider to submit claims for covered
services without the approval of the noncustodial parent.

3. Make payments on claims submitted
pursuant to subsection 2 directly to the custodial parent, the provider or an
agency of this or another state responsible for the administration of Medicaid.

NRS 695F.470Organization to authorize enrollment of child of parent who is
required by order to provide medical coverage under certain circumstances;
termination of coverage of child.If
a parent is required by an order for medical coverage to provide coverage for a
child and the parent is eligible for coverage of members of the family of the
parent under any evidence of coverage, the prepaid limited health service
organization that issued the evidence of coverage:

1. Shall, if the child is otherwise
eligible for that coverage, allow the parent to enroll the child in that
coverage without regard to any restrictions upon periods for enrollment.

2. Shall, if:

(a) The child is otherwise eligible for that
coverage; and

(b) The parent is enrolled in that coverage but
fails to apply for enrollment of the child,

Ê enroll the
child in that coverage upon application by the other parent of the child, or by
an agency of this or another state responsible for the administration of
Medicaid or a state program for the enforcement of child support established
pursuant to 42 U.S.C. §§ 651 et seq., without regard to any restrictions upon
periods for enrollment.

3. Shall not terminate the enrollment of
the child in that coverage or otherwise eliminate that coverage of the child
unless the prepaid limited health service organization has written proof that:

(a) The order for medical coverage is no longer
in effect; or

(b) The child is or will be enrolled in
comparable coverage through another insurer on or before the effective date of
the termination of enrollment or elimination of coverage.

NRS 695F.480Organization prohibited from restricting coverage of child based
on preexisting condition if person who is eligible for group coverage adopts or
assumes legal obligation for child.

1. If a person:

(a) Adopts a dependent child; or

(b) Assumes and retains a legal obligation for
the total or partial support of a dependent child in anticipation of adopting
the child,

Ê while the person is eligible for group coverage under any
evidence of coverage, the prepaid limited health service organization issuing
that evidence of coverage shall not restrict the coverage of the child based
solely on a preexisting condition the child has at the time he or she would
otherwise become eligible for coverage pursuant to that evidence of coverage.
Any provision relating to an exclusion for a preexisting condition must comply
with NRS 689B.500 or 689C.190, as appropriate.

2. For the purposes of this section,
“child” means a person who is under 18 years of age at the time of his or her
adoption or the assumption of a legal obligation for his or her support in
anticipation of his or her adoption.